Mx Labour Part 2 Flashcards
How is fetal blood sampling done
Amnioscope - tiny amount blood = removed from scalp for pH + BE to be measured
Indicated FBS ((5)
Persistent late/variable decelerations on CTG
Persistent fetal tachycardia
Prolonged + persistent early decelerations
Signif meconium stained liquor along w/ any CTG abnorm
Prolonged loss of baseline variability
C/I FBS (3)
If risk of infection transmitted from mother
Fetal bleeding diathesis
<34w gestation
FBS - If pH is found to be 7.20-7.25, what should be done
Repeat at 30-60 mins
FBS - if pH is found to be <7.2, what should be done
Delivery by CSC, ventouse or forceps
FBS - BE value > -8 indicates
Metabolic acidosis
What substances can affect FBS results (3)
Amniotic fluid
Meconium
Maternal blood
What can the presence of meconium in liquor signify?
Signs of fetal distress
Why does meconium staining occur?
Stimulation of CNX (parasym) in utero –> foetal gut to contract + anal sphincter to relax
Meconium staining - grade 1
Good volume of liquor stained lightly w/ meconium
Meconium staining - grade 2
Reasonable volume of liquor w/ heavy suspension of meconium
Meconium staining - grade 3
Thick undiluted volume of meconium, pea soup consistency
if meconium is found below the vocal chords, what is this called
Meconium aspiration syndrome
What is Meconium aspiration syndrme
Neonatal pneumonitis
When is meconium aspiration syndrome likely to be more severe?
of assoc w/ acidosis/hypoxia
when meconium = thick
Non-medical pain relief options during labour (6)
Birth attendant Maintenance of mobility immersion of body T H2O Aromatherapy Hypnotherapy TENS
Inhalation agent used for pain relief during labour
Entenox
NO + O2 mix
SE entenox (3)
Light-headedness
Nausea
Hyperventilation
What systemic opiates are used for pain relief during labour? (2)
Pethidine
Meptid (IM)
SE foetus of systemic opiates during labour
Respiratory depression
reverse w/ naloxone
How are epidural anaesthesia delivered
Via epidural catheter into epidural space between L3-4/L4-5
Advantages - epidural anaesthesia during labour (3)
Only pain free method
If labour too long, can reduce BP
Abolishes premature urge to push
Disadvantages - epidural anaesthesia during labour (10)
Occasionally ineffective IV access req Transient HOTN (after loading dose) Mobility reduced - P sores Urinary retention Maternal fever Increased need for instrumental delivery Pushing needs to be directed Active 2nd stage delayed Transient bradyC
C/I epidural (5)
severe sepsis Some spinal abnorm Active neuro disease Hypovolaemia Coagulopathy/anti-coag therapy
How is spinal anaesthesia performed
LA into dura mater
Complications spinal anaesthesia
HOTN
Total spinal analgesia –> resp paralysis
How is a pudendal nn block performed
LA injected biblaterally around pudendal nn
Where it passes ischial spines
Indications - forceps delivery - foetal (3)
Foetal distress
Face presentation
Known/suspected foetal bleeding disorder
Indications - forceps delivery - maternal
Prolonged 2nd stage labour Prev pathologies: > Pre-eclampsia > Berry Aneurysm > UA > Brittle asthma > Prev pneumothorax
6 steps in forceps delivery
1 - anaesthestics for foreceps
2- ensure bladder is empty
3 - feel - is cervix still palpable? which way is head?
4 - select type of forceps
5 - If baby in OA - grease up Neville Barnes forceps + insert
6 - if baby not in correct position - grease up Keilliands forceps + use Wandering method
What are the 2 types of forceps
Neville Barnes Forceps - traction (fixed lock)
Kelliands forceps - rotation (sliding lock)
When using Neville Barnes forceps, if you do 3 pulls, and there is no descent, what to do
STOP due to damage to facial nn (b/c disproportion)
hence
episiotomy
What is the wandering method
When anterior blade is 1st inserted posteriorly and then wandered over the face to lie anteriorly
What is asynclitism
Oblique malpresentation of fetal head in labour
Indications - ventouse delivery (3)
If delayed 2nd stage labour b/c mum = exhausted
If delayed 2nd stage labour b/c malposition
If abnorm CTG
Method - ventouse delivery
KIWI cup
Over posterior fontanelle
Traction downwards initially, changing angle upwards as head crowns
how long, from application must a ventouse delivery be complete by?
15 mins
If foetal head is above ischial spines, what method of delivery must be used
CSC
Risks of assisted delivery (7)
Laceration to vagina Perineal trauma Rupture bladder Skull fractures Chignon (baby) Brain bleed baby Facial palsy
What is Chignon
Scalp oedema
Purpose of episiotomy
Increase diameter of vulval outlet
What episiotomy technique is used in the UK?
Epidural/ perineal infiltration w/ LA
+ Mediolateral incision
What must be done after suturing up an episiotomy
VE
PR
Maternal indications episiotomy (2)
Female circumcision
If prev perineal reconstructive surgery
Fetal indications episiotomy (4)
Instrumental delivery
Breech
Shoulder dystocia
Abnormal CTG
What % of mothers have some degree of tear during labour
70%
1st degree tear
SKin only
2nd degree tear
Skin + perineal mm
3rd degree tear
Incl partial/complete rupture anal sphincter
4th degree tear
Anal mucosa
Maternal indications CSC (7)
2 previous LSCS Placenta praevia Maternal disease Fibroids/ovarian cyst Maternal request Active 1' genital herpes HIV
Fetal indications LSCS (7)
Breech Twin pregnancy - 1st not cephalic Abnorm CTG/FBS Selected cases of placental abruption Cord prolapse Delay in 1st stage labour Cephalopelvic disproportion
What incision is used in LSCS
Pfannenstiel incision
Steps of LSCS
Regional analgesia Pfannenstiel incision Empty bladder w/ catheter Rectus sheath cut + mm divided Uterovesical peritoneum incised Lower uterine segment incise transversely, fetus delivered IV Oxytocin + placenta + membranes removed Uterus closed by absorable suture
Risks CSC (7)
Adhesions Visceral injury Lacerations to babies face Infection Haemorrhage Gastric aspiration (Mendelsons syndrome) Thomboembolism
What is VBAC
vaginal birth after CSC
VBAC - risk of scar rupture
5%
What is shoulder dystocia
Normal traction fails to deliver shoulders after head because = too big
Complications of shoulder dystocia (2)
Brachial plexus damage (Erb’s palsy)
Neonatal mortality
RF shoulder dystocia (5)
Diabetes / large baby Prev baby w/ shoulder dystocia Incr BMI IOL Decr maternal height
Mx shoulder dystocia
Sr obstetrician/paids
Suprapubic P
McRoberts maneouvre
Episiotomy
Transverse shoulder - int rotation of shoulder
If fails:
Grasp post arm. Hand brought down + trunk follows, rotate body using arm
LAST resort - symphisiotomy + replacement of head + CSC
Mc Roberts Manoeuvre
Leg hyperextesnion onto abdomen
Prevalence cord prolapse
1/500
Complications of cord prolapse
Cord spasm –> rapid fetal hypoxia –> mortality
RF (5)
Pre-term Breech Polyhydramnios Abnorm lie Multiple pregnancy
Mx of cord prolapse
Prevent compression via finger + tocolytics
If out of vag - keep warm/moist + don’t force back inside
Can push back present part of foetus
Pt on all 4s –> CSC
What is amniotic fl embolism
When amniotic liquor enters the maternal circulation
Consequences amniotic fl embolism (4)
Maternal death
Rapid DIC
Pulm oedema
ARDS
RF amniotic fl embolism (4)
ROM
CSC
TOP
Polyhydramnios
Mx amniotic fl embolism
Resus O2 Blood - clotting/FBC/e=/Cross match Blood + FFP ICU
What is uterine rupture
A new tear or rupture of CSC scar
PS uterine rupture (5)
Constant lower abdo pain Decr Fetal HR Vaginal bleeding Cessation of contraction Maternal collapse
Complications uterine rupture (5)
Foetal extrusion
Masssive internal haemorrhage
Acute fetal hypoxia
Neonatal mortality
RF uterine rupture (4)
Prev CSC
Prev rupture
Deep myomectomy
Obstructed labour
Mx uterine rupture
Resus incl fl/bloods/FFP
Urgent laparotomy
Preventing uterine rupture (2)
Avoid IOL in VBAC
Use transverse CSC
What is uterine inversion
Fundus inverts into uterine cavity, usually after traction on placenta
Complications uterine inversion (3)
Pain
Shock
Haemorrhage
Mx uterine inversion
Attempt to push fundus throguh vagina
Replace HSP
RF - seizures in labour (3)
PE
Epilepsy
Hypoxia
Mx seizures in labour (5)
Open airway O2 Cardiopulm resus diazepam MgSO4 if /b/c PE
